Through collaborative use of improvement science methods, reduce preterm births &

improve perinatal and preterm newborn outcomes in Ohio as quickly as possible.

Barrier Analysis: Using QI Methodology to Decrease Recurrent Preterm Birth:

Lessons from an Urban Safety Net Hospital

Jodi F. Abbott, MD MHCMBoston Medical Center

Boston University School of Medicine

Learning Objectives

• Discuss how models of implementation science can be applied to preterm birth prevention

• Model how a barrier analysis of allows adaptive change mechanisms to increase success in 17OHP

• Share specific interventions potentially adaptable to your sites

Barriers to receipt of 17OHPC/ Sources of care disparities

Patient-level factors•Beliefs and preferences•Race/ethnicity, culture, family•Education and resources•Biology

Clinical encounter•Provider communication•Cultural competence

Provider factors•Knowledge and attitudes•Competing demands•Implicit/explicit biases

Health system factors• Health services organization, financing, delivery• Health care organizational culture, QI

Structural factors• Poverty/wealth• Unemployment• Stability of housing• Food security• Racism Adapted from Kilbourne et al,

AJPH 2006

Health Belief ModelPerceived

susceptibility to the problem

Perceived consequences of

the problem

Perceived benefits of the

action

Perceived barriers to

action

Perceived threat

Outcome expectations

Self efficacy

Health Belief ModelPerceived

susceptibility to the problem

Perceived consequences of

the problem

Perceived benefits of the

action

Perceived barriers to

action

Ambulatory interventionsSubsequent Pregnancy

Self efficacy

Hospital Intervention at

1st preterm birth

Theory of Planned BehaviorAttitudes toward

the behavior

Subjective norms

Perceived behavioral

control

Behavioral intention

Actual behavioral control

Behavior

• New England’s Largest Safety Net hospital

• 50% Families have an income <$20,000 (Federal Poverty Level)

• 30% non English Speaking• 68% Speak language other than

English at home• We deliver 70% of Black and Latina

women in the City of Boston

Identification of the problem

• Root cause analysis of ”missed” identification of women at risk of recurrent preterm birth

• Identified a number of factors in our system leading to failure to identify women with prior preterm birth

• Identify processes and the necessity to identify and measure ability to impact interventions

• Most significant barrier was lack of patient awareness, education and empowerment

Barrier Analysis

Rapid assessment tool used to identify behavioral determinants associated with a particular behavior so that more effective behavior change messages and support activities can be developed

Process of Barrier Analysis

IDENTIFY DO-ER’s and NON DO-ER’s

Process of Barrier Analysis

IDENTIFY DO-ER’s and NON DO-ER’s

IDENTIFY DETERMINANTSWhy people do or not do the behavior

The underlying goal of this project is to decrease health disparities in infant mortality and preterm birth and to

diminish the number of preterm deliveries

90% of women at Boston Medical Center (BMC) with a prior spontaneous preterm delivery (SPTD) will have counseling for

progesterone and serial cervical ultrasounds in a subsequent pregnancy by

January 2015

AIM:

•Prior authorization

•Late presentation

•Discharge•EHR communication

•Type•Knowledge•Site

•Lack of knowledge

•No self advocacy•Language barrier

Patients Providers

17 OHPRecords

Barrier• Lack of knowledge of

preterm birth• No information that

their history is a risk factor for preterm birth

• No history of self advocacy

• 64% non English speaking

• Perception of divine will

Intervention• Campaign to

standardize identification and counseling of patients at index spontaneous preterm birth

Patients

Counseling and Documentation at Index SPTD

SPTD pts on MFM pp service

Education campaign for faculty & residents

Stickers & EmailsPosting protocol

ProvidersBarriers• Patients see a variety

of physician and non-physician providers

• Providers are unaware of history of preterm birth

• Providers are unaware of SMFM/ACOG recommendations

Interventions• Series of educational

events at grand rounds • Reminders at

workstations• Transfer of patients with

SPTD to MFM pp service• Enhanced Partnership

with Community Health Centers and Boston Public Health Commission

Challenges of Obtaining 17 OHP

Barriers• Myriad sites and providers

trying to obtain 17 OHP• Providers unaware of

process of obtaining 17OHP

• Prior Authorizations needed for publically & privately insured patients with different forms

• Women who present after 20wks cannot obtain 17OHP

Interventions• Centralized resource

for process of prior authorizations

• Centralize pharmacy so med available

• Increased the number of women identified before 20 wks who are candidates for 17OHP

Initial Process Map for 17OHP Receipt by patients with prior Spontaneous PTD

Patient Calls for

appt

Intake by CNM

Identify hxPTD

MFM Consult ID 17OHP candidate

Order 17OHPSchedule cx

US

Insurance and timing

ID'dPrior

Authorization

Approval of Med Notify

patient

Order sent to pt choice pharmacy

Pharmacy does/doesn’t

get medPt. picks up

17OHP

Pt. brings

med and receives

1-2 weeks

1-2 weeks Few days

1-4 weeks

1-14 days

1-14 days

1-7 days

1-7 days

Total Delay from 1st call for appointment to receiving 17 OHP

commonly 8-12wks

Initial Process Map for 17OHP Receipt by patients with prior Spontaneous PTD

Patient Calls for

appt

Intake by CNM

Identify hxPTD

MFM Consult ID 17OHP candidate

Order 17OHPSchedule cx US

Insurance and timing

ID'dPrior

Authorization

Approval of Med Notify

patient

Order sent to pt choice pharmacy

Pharmacy does/doesn’t

get medPt. picks up

17OHP

Pt. brings

med and receives

1-2 weeks

1-2 weeks Few days

1-4 weeks

1-14 days

1-14 days

1-7 days

1-7 days

Total Delay from 1st call for appointment to receiving 17OHP

commonly 8-12wks

Pt identifie

d at Fetal

Survey with hxof SPTD

Amended Process Map for 17OHP Receipt by patients with prior Spontaneous PTD

At intake call ask: have you ever delivered a baby >3wks before your due date?

Appt for 1st PN intake visit AND call MFM PA if hx of cerclage

or previable loss

MFM Consult ID 17OHP

candidate Schedule cx US

Insurance and timing ID'd

Prior Authorization

Approval of Med Order at BMC

pharmacy Notify patient

Pt. picks up 17OHP

receives1-2 weeks

Few days

1 week

Decreased delay from 1st call for appointment to receiving 17OHP to 7-

10 days

Pt identified at Fetal Survey

with hx of SPTDOrder 17OHP

Few days

Record KeepingBarriers• Patients not identified by

providers as having SPTD

• Discharge summaries did not include mention of spontaneous preterm delivery

• Many sites with different EHR’s

• Our system changed EHRs twice in the last two years

Interventions• Smart texts developed

for problem lists and discharge summary

• “Preterm delivery” needs to be unlinked from pregnancy episode

• EPIC transformation increased communication across health system

Lessons Learned: Unsuccessful Interventions

• Grand rounds/Resident lectures

• Jodi sings a preterm labor song

• Processes excluding patients

• Failing to prioritize preterm birth as an obstetric RISK event

• Trying to communicate priorities without data

Lessons Learned: Successful Interventions

• Counseling at delivery of index pregnancy

• Experiential counseling of patients by residents

• Focused identification of patients• Streamlined processes• Assigning 17OHp Resource RN • EMPOWERED Patients are ready for

17Ohp• Audit and feedback of providers• Partnership with local DPH & CHC’s

Thera Wilson RN17OHP Prior Auth

Queen

BMC Initiative to Prevent Recurrent Preterm Birth

Identify Women with a History of Spontaneous

Preterm Birth < 37 weeks

MFM ConsultCervical US until

30wks17 OH Progesterone

16-36wks

Cervix <2.5cm <24wks

Cervix <2.5cm >24wks

Cervical Cerclage Betamethasone

Consult can be done in ATU17OHP needs a

prior authorization

“Spontaneous” delivery NOT due to

preeclampsia or IUGRCall 414-2000

to book ATU appts

Protocol as per SMFM, ACOG and Boston Public Health Commission guidelines

27

$2,470,000Cost Savings/Year

180Patients/year

Boston Medical Center Projected Annual Cost Savings

By Recurrent Preterm Birth Averted

72%reduction in

Preterm delivery

52 BMC patents

delivered prematurely

29%BMC Preterm delivery rate

38BMC preterm births averted

Cost of preterm delivery in Massachusetts ~$65,000

March of Dimes Peristats 2014

Evidence Based Quality Improvement:

Classification of professional interventions from EPOC

• DISTRIBUTION OF EDUCATIONAL MATERIALS• EDUCATIONAL MEETINGS• LOCAL CONSENSUS PROSESSES• LOCAL OPINION LEADERS• PATIENT MEDIATED INTERVENTIONS; NEW INFORMATION

FROM PATIENT COLLECTED INFORMATION• AUDIT AND FEEDBACK• REMINDERS (PROMPTS)• MARKETING• MASS MEDIA

EPOC TAXONOMY: Cochrane Effective Practice and Organization of Care

Evidence Based Quality Improvement: What are Effective WAYS to implement guidelines?

• Passive dissemination (emailing article) largely ineffective

• Reminders and educational dissemination mostly effective

• multifaceted interventions are most effective

Grimshaw, J., Eccles, M., Thomas, R., MacLennan, G., Ramsay, C., Fraser, C. and Vale, L. (2006), Toward Evidence-Based Quality Improvement. Journal of General Internal Medicine, 21: S14–S20. doi: 10.1111/j.1525-1497.2006.00357.x

Rates of Unintended Pregnancy in the US

Guttmacher Institute 2014

Rates of Unintended Pregnancy in OHIO

Shah, Prakesh S., et al. "Intention to become pregnant and low birth weight and preterm birth: a systematic review." Maternal and child health journal15.2 (2011): 205-216.Finer, Lawrence B., and Mia R. Zolna. "Unintended pregnancy in the United States: incidence and disparities, 2006." Contraception 84.5 (2011): 478-485.

Guttmacher Institute Ohio Fact Sheet 2015

• Unintended pregnancies have an increased risk of preterm birth

Shah OR 1.58 (CI 1.1-1.6)Orr OR 1.82 (CI 1.1-3.2)

• Ohio’s unintended pregnancy rate is 49 per 1,000 overall112 per 1,000 for women below FPL

• 109,000 pregnancies: 65,000 births• Leading to a Preterm Birth Rate of

25% and 16,350 preterm births/year

A reduction in Ohio’s unintended pregnancy rate to 40 per 1000 would lead to 3,270 fewer preterm births

Cost savings of $98 million dollars

Next Steps/Challenges:

• Boston Medical Center: Pilot Implementation of a Community Liaison “Prematurity Navigator”

• Implementation of Universal Cervical Length Screening

• Massachusetts PQC: • Template for Rapid Site Resource Identification • Projects to Increase Data Accuracy of Progesterone Use/Access in

Appropriate Populations• Unlinking of Contraceptive Implants with Delivery Bundle

Thank you